No abstract

Stereotactic radiosurgery has long been recognized as the optimal form of management for high-grade arteriovenous malformations not amenable to surgical resection. Radiosurgical plans have generally relied upon the integration of stereotactic magnetic resonance angiography (MRA), standard contrast-enhanced magnetic resonance imaging (MRI), or computed tomography angiography (CTA) with biplane digital subtraction angiography (DSA). Current options are disadvantageous in that catheter-based biplane DSA is an invasive test associated with a small risk of complications and perhaps more importantly, the two-dimensional nature of DSA is an inherent limitation in creating radiosurgical contours. The necessity of multiple scans to create DSA contours for radiosurgical planning puts patients at increased risk. Furthermore, the inability to import two-dimensional plans into some radiosurgery programs, such as Cyberknife TPS, limits treatment options for patients. Defining the nidus itself is sometimes difficult in any of the traditional modalities as all draining veins and feeding arteries are included in the images. This sometimes necessitates targeting a larger volume, than strictly necessary, with stereotactic radiosurgery for treatment of the AVM. In this case report, we show the ability to use a less-invasive and three-dimensional form of angiography based on time-lapsed CTA (4D-CTA) rather than traditional DSA for radiosurgical planning. 4D-CTA may allow generation of a series of images, which can show the flow of contrast through the AVM. A review of these series may allow the surgeon to pick and use a volume set that best outlines the nidus with least interference from feeding arteries or draining veins. In addition, 4D-CTA scans can be uploaded into radio-surgery programs and allow three-dimensional targeting. This is the first reported case demonstrating the use of a 4D CTA and an MRI to delineate the AVM nidus for Gamma Knife radiosurgery, with complete obliteration of the nidus over time and subsequent management of associated radiation necrosis with bevacizumab.

Atrioventricular discordance with ventricular-arterial discordance is a rare cardiac anomaly known as congenitally corrected transposition of the great arteries (CCTGA). This malformation has a prevalence of 0.4-0.6% of all congenital heart disease cases. Complete heart block develops in up to 30% of patients with CCTGA. We present the case of a 62-year-old woman diagnosed with CCTGA who, on echocardiography, had anomalous venous drainage where the inferior vena cava (IVC) bypassed the right atrium and drained into the azygos system. Complementary images with magnetic resonance imaging demonstrated the unique anatomical relationship between the IVC, azygos venous system, and the superior vena cava.

Oncocytomas, called oxyphil proximal tubular adenomas in the Anglo-Saxon literature, and benign hypernephromas are non-malignant, usually symptomless, rare tumours belonging to the renal adenomas. Oncocytomas have angiographic appearances sufficiently uniform to permit a tentative diagnosis. Histologically benign hypernephromas do not possess characteristic angiographic appearances and, in the presence of tumour in the renal vein or necrotic avascular areas, must be regarded as potentially malignant.

Background: Delay in symptom recognition and calling 911 for patients with ST-segment elevation myocardial infarction (STEMI) continues to challenge many hospitals’ STEMI systems. Research has historically focused on door-to-balloon time and inpatient treatment, with little known on the impact of engaging emergency services (EMS) to provide a team approach to patient care, from community education to prehospital activation. Purpose: Evaluate the impact of a collaboration with local EMS agencies in our institution’s STEMI system designed to develop a prehospital protocol and joint community education efforts. Methods: Data collected from NCDR ACTION Registry-Mission Lifeline reports from 2011 to 2013 was analyzed to identify recent trends in prehospital STEMI quality metrics. After evaluation of 2011 data, a regional plan was developed and implemented in 2012 to address prehospital system barriers, including public education and revision of a prehospital protocol. Results: In 2011, a majority of patients used private transport when having a STEMI. Following protocol implementation, STEMI patients were able to identify symptoms earlier and appropriately call 911 earlier. As a result, a first medical contact (FMC)-to-balloon time of < 90 minutes increased to 72% of patients, time from symptom onset to balloon decreased, and postprocedure complication rate improved (Table). Conclusions: Establishing a collaborative prehospital protocol between hospitals and EMS can have a positive impact on outcomes in STEMI patients. With more awareness and earlier notification of incoming STEMI patients, hospitals can significantly decrease symptom onset-to-balloon time. Evaluation of time from symptom onset to device activation may be a better way to measure quality than door-to-balloon time, as evidenced by a decrease in postprocedure complications associated with decreased overall times.